The United States has a large and aging population of limited English proficient (LEP) individuals. These patients experience significant communication barriers, which lead to disparities in access, utilization, outcomes and satisfaction. These barriers are compounded for the elderly who frequently rely on non-English speaking informal caregivers, particularly during transitions of care from hospital to home. Access to professional medical interpreters for older LEP hospitalized patients is critical to effective communication and the delivery of high quality care. However, even in medical centers with professional staff interpreters, hospitalized patients rarely have access to professional interpreters. This is in part because of the frequent and brief nature of many interactions, time pressures, the need for advance scheduling for in-person interpreters, and the twenty-four hour nature of hospital care. To overcome these barriers, we have developed the bedside interpreter intervention: use of dual- handset interpreter phones at the bedside of every LEP patient. Usual care communication in our hospital includes in-person staff interpreters who can be scheduled during business hours, and one to three dual handset interpreter phones at most nursing stations. Immediate availability, bedside location and 24 hour access allow for use of the dual-handset interpreter phone by any clinician for even the briefest interaction. The underlying hypothesis of this proposal is that the bedside interpreter intervention will improve communication with older hospitalized LEP patients compared to usual care. We will test this hypothesis from three perspectives: the health care system (Aim 1, administrative data), the patient and caregiver (Aim 2, structured interviews), and the clinician (Aim 3, focus groups).
First (Aim 1), we will use an interrupted time series design with switching replications using administrative data to compare hospital outcomes for two patient samples of older (e50 years) LEP patients admitted to the UCSF Medical Center. The data collection for the first sample will focus on patients admitted to the general Medicine floor in the 18 months which preceded the implementation of the bedside interpreter intervention in 2008 and in the 12 months after implementation. We will then collect data for an additional sample of patients admitted to the Cardiology floor in the 18 months before and in the 12 months after implementation of the intervention on that floor (in 2012). Next, (Aim 2), we will assess the usefulness and acceptability of the bedside interpreter intervention to LEP patients and their informal caregivers by prospectively collecting primary data using structured interviews with older Chinese- and Spanish-speaking LEP patients admitted to the Cardiology floor and their informal caregivers recruited during 6 months pre- and 6 months post-implementation of the intervention on the Cardiology floor. We will survey patients at two time points - in-person in the hospital and one month post-discharge by telephone - and their informal caregivers once at one month post-discharge. Before and after the intervention, we will compare patterns of interpreter use and ease of access;patient and caregiver satisfaction with communication;and receipt and knowledge of discharge instructions. We will also examine these patient-reported factors as mediators for the hospital outcomes from Aim 1. Finally (Aim 3), we will conduct a qualitative study utilizing focus groups of physicians and nurses to evaluate their experience with and patterns of use of the bedside interpreter intervention, identify the types of clinical interactions best suited to this technology, and assess persisting barriers to optimal communication. If effective, the bedside interpreter intervention will be a model for hospitals across the nation to reduce disparities in care for the growing population of older LEP patients.

Public Health Relevance

This project will evaluate the effect of increasing access to professional interpreters via bedside interpreter telephones compared to usual care communication for older limited English proficient (LEP) hospitalized patients. By demonstrating this intervention's impact on health care utilization outcomes, and collecting detailed information about patient and caregiver satisfaction and knowledge and clinician utilization patterns, this proposal will provide the necessary information both to disseminate the bedside interpreter intervention locally and to serve as a model of language access for older hospitalized LEP patients across the nation.